The Impact of Implementing an Advance Practice Pharmacist-Led Anticoagulation Clinic Within a Correctional Facility

Abstract

Maintaining warfarin in the therapeutic range is clinically challenging and can be made more complex in the correctional health setting. The care of an inmate population is complicated by its episodic and often brief nature in addition to the frequent lack of consistent care prior to incarceration. As part of a process improvement effort, a descriptive study was conducted on a unique pharmacist-led anticoagulation clinic that was initiated in the Los Angeles County jail. The advanced practice pharmacist (APP) used a Collaborative Practice Agreement and had access to a physician supervisor when necessary. The patients who arrived to the jail on warfarin had their doses adjusted by the APP according to their respective international normalized ratio (INR). The primary endpoints were percentage of INR readings within therapeutic range (RR) and time in therapeutic range (TTR). Secondary endpoints included bleeding and thrombotic events. A total of 141 patients were followed by the anticoagulation clinic over the initial 8-month period from September 2017 to April 2018. Indications for warfarin included deep vein thrombosis or pulmonary embolus (67%), mechanical valve (17%), atrial fibrillation (8%), and other (8%). The average RR was 74.1% in the 8 months following APP management, which met the definition of good control (>65%). The TTR was 67% which met the definition of good control (>65%). No bleeding or thrombotic events that required hospitalization occurred. Implementation of an APP-led anticoagulation clinic in a correctional health setting resulted in good INR control as defined in community standards.